Summit a chance to end nation's decades-long drinking binge

Published in Australian Medicine 25 November 2014

Ebola demands our full attention

The cheery and intelligent man who operates our local dry cleaning agency and I often chat. He has a son doing medicine, and last week, he was worried about Ebola.

He feared that casual contact in his shop or, in the case of his son, on the wards might lead to the disease.  

It made me realise that it is easy to overestimate community understanding of the basic facts about Ebola.

Not that as health professionals we know all there is to know about it - even the precise details of its transmission are uncertain - but sharing what we do know can help the public manage its anxiety.

And quality vigilance depends on good intelligence. So what do we know? The first good thing - and there are not many - is that over half the people who contract it recover.

It is less certain how recovery occurs and whether classic principles of immunity apply, but a 50% recovery rate is a lot better than we saw with HIV in the early years.

Medical care also helps. Fluid replacement and intensive care make a difference to survival chances.

Second, the disease thus far appears to spread through blood, sweat and other body fluids, especially the excreta of infected people, to those who touch them during life or death.  Airborne transmission has not been documented.

In theory, this means that enhanced infection control procedures can protect family and health professionals.

However, as of the end of October, about 500 healthcare workers had contracted Ebola and half of them had died, so protection as practised at present is far from perfect.

Third, we live in an age of brilliant technological possibility, so the search for a drug to treat Ebola or a vaccine to prevent it is likely to yield dividends quickly.

The most likely limits, with so few cases, will be political and economic, as the cost of developing a drug or vaccine may not be a good commercial deal. But the accolades that would come to the inventor of a drug or vaccine would be great.

Furthermore, technological fixes are not always expensive. As reported in the 27 October issue of the New Yorker, a recent competition run by Columbia University yielded several inexpensive innovations designed to assist in managing Ebola.

The competition, auspiced by the schools of public health, and engineering and applied sciences, was open to all students and faculty. Among them was an inexpensive hose that sprayed bleach foam rather than a solution, because unlike a bleach solution, with foam you can see where it has been sprayed. 

But there are significant endemic barriers to combating the virus in West Africa.

The impoverishment of the countries where Ebola has become an epidemic is a major limitation, both in the treatment of those with the disease and the control of its spread. 

Poverty means fewer healthcare facilities and medical supplies, which is why the military support offered by the US, with its sophisticated logistic capability, will make a huge contribution.

Last month, 4000 US troops with cargo planes stuffed with all necessary equipment and transport were deployed to Monrovia in Liberia as part of Operation United Assistance.

With that as a background, groups such as Médecins Sans Frontières and other NGOs' efforts will be enhanced by field hospitals and supply lines for IV fluids and material needed to care for Ebola patients.

Medical volunteers from Australia are also contributing to the Ebola effort ­- including supporting diagnostic laboratories that are hard-pressed to keep up in the affected countries, and are working with MSF and the Red Cross on the front line. 

This month, the Federal Government pledged $20 million in funds for the private healthcare company Aspen Medical to operate a 100-bed hospital in Sierra Leone that will be run by 240 healthcare staff, some of whom will be Australian.

The move came after weeks of public accusations by the AMA and NGOs that the government was not doing enough. 

However, until effective treatment and infection control measures are more widely implemented in Africa, the course of the epidemic is hard to predict.

I understand that the mutagenic potential of the Ebola virus is no match for influenza, but if its mode of transmission does expand to include airborne routes, the challenge of the epidemic would grow enormously.  

Figures published by the US Centers for Disease Control and Prevention say almost 5000 people in West Africa have died from the virus, with the number of cases in Sierra Leone and Liberia said to be doubling every 20 days, which means that by year's end, those affected will be approaching 1.4 million.

It is clear Ebola deserves our serious attention: just as we view the extremist Islamic State as a distant threat to Australian security, so too we should view Ebola.  

As for my friend the dry cleaner, when he asked if he should wash his hands after handling unfamiliar garments, my cautious (but not entirely rational) answer was, yes.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 17 November, 2014 http://bit.ly/16p4FTz

H2O: putting health on the global agenda

Published in Australian Medicine 28 October 2014
 

Stronger focus on drug side effects needed

Randomised controlled trials are the supreme method for determining whether a new treatment, frequently a new pharmaceutical, is superior to current best practice.

They were originally used in agriculture to assess the added value of a new plant or soil additive, but are now firmly ingrained in medical practice.

I recall 30 years ago, an eminent professor of surgery railing against randomised controlled trials, which he considered utterly inappropriate to determine the value of surgical interventions.

He wrote a scathing article in which he referred repeatedly and disparagingly to such trials as "agricultural statistics".

While the randomised controlled trial has given us the best possible evidence about the effects of new therapies for a range of conditions, especially cancer and cardiovascular disease, and have underpinned the evidence-based medicine movement, they do not cover the entire treatment waterfront. This is especially so in relation to side effects.

The way randomised controlled trials work is that they aim to find out how many patients need to be treated — either with the new therapy or the old — to determine if the new drug is better.

The expected improvement in cancer trials is small, usually less than 10%, and so these studies require larger numbers of patients to be sure that even the slightest difference in outcome can be seen.

Sample size calculations, therefore, are based on the detection of relatively rare events, such as a gain in life expectancy or quality of life.

But side effects are another matter. They often fall beyond the vision of the trial, or out of focus of its carefully calculated sample size.

Side effects may not occur for months or years after a trial has finished, or they may be so rare that the randomised controlled trial's sample size is insufficient to detect them, even if they occur during the trial.

With some medications, side effects are of huge importance — for example, if the trial is testing a preventive intervention such as immunisation, rather than a treatment for a serious illness where side effects may be tolerated.

Nobody wants to enter a trial feeling whole and well and leave it with a nasty side effect.

Publicity around claims of side effects from immunisation illustrate this point, and show how critical it is to be secure about the proposed preventive interventions.

Similar concerns surround trials of cholesterol-lowering drugs in very low-risk populations. Side effects can be hard to detect, and if the treated trial subjects are at low risk of the disease (such as an MI) that the drug is intended to reduce but then develop problems with, for example, muscle power, a hard-to-resolve problem arises. Witness the controversy around the Catalyst TV programs on exactly this topic.

So there is a sizeable challenge to be sure that we know what side effects occur, and brilliant randomised controlled trials will not necessarily tell us about rare and distant ones.

Currently, especially in the case of new drugs, the pharmaceutical company sponsoring the trial will have given serious thought to this matter and have in place systems to collect information about side effects.

Of course, it is not only in the context of randomised controlled trials that side effects occur and old remedies, especially in specific genetic subsets of the population, may cause rare problems. Often more information, especially long-term data, is needed.

An intelligence system to learn about possible side effects is far more feasible today than even 10 years ago.

The high degree of electronic connectivity that we all enjoy (and sometimes loathe) can put us in touch with agencies, such as the TGA, to report possible side effects at the click of a mouse.

Now the TGA has come up with an online reporting system for patients as it's concerned that the vast majority of side effects go unreported. Doctors report some and drug companies others, but for over-the-counter and alternative medicines, there have been no formal reporting pathways.

The TGA may easily be overwhelmed with side effect noise and it will need a good filtering system to detect the signals. But this is surely a move in the right direction; another step to ensure medication safety as well as efficacy as we continue to advance our capacity to prevent and to treat.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 8 October 2014 http://bit.ly/1BRzk91

 

Coming to terms with Ebola

Published in Australian Medicine, 30 September 2014